CAL STATE LA LSAMP – BRIDGE TO THE DOCTORATE
APPLICATION FORM
Program Components
Participating students will focus on activities that will enhance their preparation for PhD studies in science, engineering and mathematics (SEM). LSAMP-BD Program at California State University,
Los Angeles (Cal State LA) includes completion of a Master of Science degree and entrance into a
PhD program in a SEM discipline. LSAMP-BD fellows are expected to complete the Master of
Science degree in science, mathematics or engineering within 24 months, beginning August 1, 2016 and ending July 31, 2018. It is expected that LSAMP-BD Scholars will begin PhD programs by Fall
Term 2018. Each participant will receive a $32,000 stipend per year for two years as long as targeted goals are achieved. In addition, LSAMP-BD will pay for California Resident tuition and fees, limited research supplies, and limited travel to professional conferences to present research results. Program activities are designed to ensure that each LSAMP-BD fellow:

pursues a rigorous curriculum of graduate study leading to a MS degree in a SEM discipline in two years;

participates in a project of original research and acquires the skills required to communicate the outcomes in written and oral formats [written thesis, publication(s) in peer-reviewed journal(s), presentation(s) at national scientific conferences, presentation at departmental seminar or other oncampus program functions];

receives intense advising, mentoring and academic support necessary to become a confident and successful graduate student; and

achieves competitive scores on the Graduate Record Exam (GRE) general & subject tests to support acceptance into a high quality PhD program.
Eligibility Criteria
Please be advised that no action will be taken on your LSAMP-BD application until your application to graduate school (MS PROGRAM) is complete. The deadline to apply to MS
PROGRAM is department-specific and may be significantly earlier than the deadline for the
LSAMP-BD application.
In order to be eligible for the LSAMP-BD research fellowship, you must (1) have been a participant in an LSAMP (also called CAMP or AMP) program at your undergraduate institution and (2) have applied to and been accepted for admissions to the Cal State LA Graduate School and to the specific department in which you intend to receive the Master of Science degree. Deadline to apply to Cal
State LA graduate school via CSU Mentor varies according to specific SEM department: as early as
March 15, 2016 to as late as May 1, 2016 (see links on next page for specific SEM department deadlines) .
The funding for this program is pending approval by the National Science Foundation.

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Important Links to Cal State LA Graduate Application & SEM Departments

To apply to graduate school, complete the on-line application form at: http://www.csumentor.com/admissionapp/grad_apply.asp
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For more info on Cal State LA graduate school: http://www.calstatela.edu/academic/aa/gsr
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For deadlines to apply to specific SEM departments: http://www.calstatela.edu/graduateadmissions/admission-deadlines
For more info on each SEM department at Cal State LA & additional application procedures, visit the following websites:

Biological Sciences: http://www.calstatela.edu/academic/biol
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Chemistry & Biochemistry: http://www.calstatela.edu/dept/chem/index.htm
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Civil Engineering: http://www.calstatela.edu/ecst/ce

Computer Science: http://www.calstatela.edu/ecst/cs
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Electrical & Computing Engineering: http://www.calstatela.edu/ecst/ece
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Geological Sciences & Environmental Sciences: http://www.calstatela.edu/academic/geos
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Mathematics: http://www.calstatela.edu/academic/math/
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Mechanical Engineering: http://www.calstatela.edu/ecst/me
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Physics & Astronomy: http://www.calstatela.edu/dept/physics/
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Interdisciplinary Studies: http://www.calstatela.edu/graduateadmissions/interdisciplinary-programs
The funding for this program is pending approval by the National Science Foundation. 2

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Please type your application form by highlighting each gray area if using Word file & then typing! For check boxes on Word file, double click on the appropriate boxes and change default value to “checked”.
I. BACKGROUND INFORMATION
NAME:
Last
ADDRESS:
First
Complete Street/Apt #
TELEPHONE: ( )
Please include area code
City
EMAIL:
DATE OF BIRTH:
Middle
State
DATE:
PLACE OF BIRTH:
City, State, & Country
Zip Code
GENDER:
Male
Female
Social Security #: Cal State LA CIN (assigned when you apply to Cal State LA) :
CITIZENSHIP: U.S. Citizen Permanent Resident IF NOT, LIST COUNTRY OF CITIZENSHIP:
If applicable, Permanent Resident Registration #:
Please mark at least one of the boxes provided for both “Ethnicity” and “Race.”
ETHNICITY (for statistical purposes only): Hispanic or Latino Not Hispanic or Latino
Decline to State
RACE (for statistical purposes only):
Black or African-American Asian
Native Hawaiian or Other Pacific Islander
American Indian
Alaska Native
Caucasian
Other (specify):
Decline to State
DISABILITY STATUS (for statistical purposes only): Please check “yes” if any of the disabilities listed below the check box apply to you. Otherwise, check no or decline to state.
Yes

Deaf or serious difficulty hearing
No

Blind or serious difficulty seeing even when wearing glasses
Decline to State

Serious difficulty walking or climbing stairs

Other serious disability related to a physical, mental, or emotional condition
VETERAN STATUS ( for statistical purposes only )
Are you a veteran of the U.S. Armed Forces? Yes No Decline to State
The funding for this program is pending approval by the National Science Foundation. 3

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Please type your application form by highlighting each gray area if using Word file & then typing! For check boxes on Word file, double click on the appropriate boxes and change default value to “checked”.
II. EMERGENCY CONTACT
PERSON TO CONTACT IN CASE OF EMERGENCY:
ADDRESS:
CITY:
RELATIONSHIP:
STATE: ZIP CODE:
TELEPHONE: ( ) -
III. EDUCATIONAL BACKGROUND
HIGH SCHOOL, LOCATION, AND YEAR OF GRADUATION:
UNDERGRADUATE COLLEGE OR UNIVERSITY:
UNDERGRADUATE MAJOR: DATE OF GRADUATION:
OVERALL UNDERGRADUATE GRADE POINT AVERAGE (A= 4.000, B = 3.000, C = 2.000, Do Not Round):
GRADE POINT AVERAGE IN UNDERGRADUATE MAJOR (A= 4.000, B = 3.000, C = 2.000, Do Not Round):
NAME OF THE LSAMP CAMPUS COORDINATOR AT YOUR UNDERGRADUATE SCHOOL:
IV. GRADUATE SCHOOL & CAREER PLANS
CHECK MAJOR OF PROPOSED Cal State LA MASTER OF SCIENCE DEGREE: PHYSICS
GEOLOGY ENGINEERING (AREA: )
CHEMISTRY
COMPUTER SCIENCE MATHEMATICS
ENVIRONMENTAL SCIENCE BIOCHEMISTRY BIOLOGY MICROBIOLOGY
INTERDISCIPLINARY MS (FIELDS: ); OTHER:
INDICATE WHICH FACULTY MEMBERS YOU HAVE CONTACTED AS POTENTIIAL RESEARCH MENTORS IN YOUR
PROPOSED MAJOR AT Cal State LA:
IDENTIFY YOUR HIGHEST PLANNED EDUCATIONAL LEVEL : MS PhD POST-DOCTORAL OTHER:
The funding for this program is pending approval by the National Science Foundation. 4

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APPLICATION FORM - continued
PROVIDE Date that you took the required GRE GENERAL TEST ( must be done before application is due):
Indicate your GRE General Test Raw Scores (and %): VERBAL: QUANT: ANAL:
(Additional written copy of GRE scores showing date taken and % levels required BEFORE your LSAMP-BD application is complete & accepted for review).
HAVE YOU COMPLETED YOUR ONLINE APPLICATION TO THE CSULA GRADUATE PROGRAM? YES
IF NO, EXPLAIN WHY NOT:
NO
APPLY VIA http://www.csumentor.com/admissionapp/grad_apply.asp
Most departments require that you also apply to the department. Have you applied to your major department?
YES NO IF NO, EXPLAIN WHY NOT:
V. APPLICATION MATERIALS
PLEASE ATTACH AND CHECK THE FOLLOWING ITEMS THAT YOU HAVE INCLUDED WITH YOUR LSAMP-BD APPLICATION FORM:
SUBMIT Unofficial TRANSCRIPTS OF ALL OF YOUR COLLEGE AND UNIVERSITY WORK. PROOF OF DEGREE AWARDED on official transcripts IS REQUIRED BY July 31, 2016 or BEFORE OFFICIAL ACCEPTANCE INTO THE PROGRAM.
ATTACH OR ARRANGE TO HAVE A COPY OF YOUR GRADUATE RECORD EXAM (GRE) GENERAL TEST SCORES SENT TO DR.
MARGARET JEFFERSON. WE USE THE GRE AS AN INDICATOR OF YOUR INTEREST IN PURSUING THE PhD – NO PARTICULAR
SCORE IS REQUIRED. APPLICATIONS WITHOUT GRE SCORES ARE NOT CONSIDERED FOR LSAMP-BD FELLOWSHIP.
A CURRENT CURRICULUM VITAE/RESUME THAT INCLUDES ANY ACADEMIC (OR OTHER) HONORS RECEIVED.
COMPLETION OF YOUR UNDERGRADUATE LSAMP COORDINATOR CONFIRMATION FORM (GIVE TO YOUR CAMPUS LSAMP
COORDINATOR TO COMPLETE)
ATTACH ADDITIONAL PAGES, PROVIDING SEPARATE RESPONSES TO EACH OF THE QUESTIONS PROVIDED BELOW. THE
PROGRAM ADVISORY COMMITTEE WILL USE YOUR RESPONSES TO ASSESS YOUR INTEREST IN PURSUING A RESEARCH CAREER,
AND YOUR ABILITY TO COMMUNICATE THROUGH WRITING. TYPE SEPARATE RESPONSES TO THE FOLLOWING ITEMS THAT ARE
CLEARLY LABELLED:


PLEASE DESCRIBE ANY PREVIOUS EXPERIENCE YOU HAVE IN RESEARCH OR RELATED AREAS
LSAMP-BD IS DESIGNED TO PREPARE STUDENTS FOR SUCCESS IN PhD PROGRAMS. HOW DOES THIS MESH WITH YOUR
EDUCATIONAL GOALS AND WHY DO YOU WANT TO EARN A PhD IN SCIENCE, ENGINEERING OR MATHEMATICS?

DISCUSS YOUR CAREER PLANS AFTER YOU COMPLETE YOUR FORMAL EDUCATION, PARTICULARY HOW RESEARCH FITS INTO THESE
PLANS.
 IF THERE IS A DISCREPANCY BETWEEN YOUR GRADES IN ACADEMIC COURSEWORK AND YOUR POTENTIAL, PLEASE EXPLAIN. IT IS
EXPECTED THAT YOU WILL COMPLETE THE MS DEGREE AT A 3.500 GPA OR HIGHER.
 EXPLAIN HOW YOUR SELECTION AS AN LSAMP-BD SCHOLAR WILL ENHANCE MINORITY PARTICIPATION IN RESEARCH CAREERS.
IF YOU ARE NOT A US CITIZEN, ATTACH A NOTARIZED COPY (BOTH SIDES) OF YOUR ALIEN REGISTRATION PERMANENT
RESIDENT (“GREEN”) CARD.
ARRANGE TO HAVE THREE CURRENT LETTERS OF REFERENCES WITH THE LSAMP-BD REFERENCE FORM WRITTEN AND
COMPLETED ON YOUR BEHALF BY SCIENCE, ENGINEERING, OR MATH FACULTY MEMBERS AND/OR LSAMP COORDINATOR. IF
YOU HAVE PARTICIPATED IN LABORATORY OR FIELD RESEARCH, ONE LETTER SHOULD BE FROM YOUR RESEARCH DIRECTOR . THE
RECOMMENDATION FORMS AND LETTERS SHOULD BE DELIVERED TO YOU IN SEALED ENVELOPES (SIGNED ACROSS THE SEAL) AND INCLUDED
WITH YOUR APPLICATION. IF THE LETTER WRITERS PREFER, THEY CAN SEND THE LETTERS WITH COMPLETED FORM DIRECTLY TO THE MAILING
The funding for this program is pending approval by the National Science Foundation. 5

CAL STATE LA LSAMP – BRIDGE TO DOCTORATE
APPLICATION FORM - continued
ADDRESS BELOW. EACH LETTER MUST BE SIGNED BY THE INDIVIDUAL WRITING THE LETTER OR IT WILL NOT BE ACCEPTABLE. MAKE SURE YOU
PROVIDE EACH OF YOUR REFERENCES THE REQUIRED LSAMP-BD LETTER OF RECOMMENDATION FORM WITH YOUR NAME TYPED ON THE
FORM & MAKE SURE THAT FORM IS SUBMITTED WITH LETTER.
TYPE THE NAMES AND INFORMATION BELOW FOR EACH OF THE INDIVIDUALS COMPLETING THE REFERENCE FORM & REFERENCE LETTER:
REFERENCE NAME INSTITUTION NAME PHONE NUMBER OR EMAIL ADDRESS
VI. AUTHORIZATION TO USE RECORDS
I HEREBY AUTHORIZE THE LSAMP PROGRAMS PERSONNEL TO HAVE ACCESS TO MY UNIVERSITY RECORDS FOR
PURPOSES OF ADMISSION TO AND CONTINUATION IN THE LSAMP-BD PROGRAM AT CAL STATE LA. ALL
INFORMATION WILL BE KEPT IN STRICT CONFIDENCE. THE NATIONAL SCIENCE FOUNDATION (NSF) REQUIRES THAT
WE PROVIDE STATUS REPORTS ON EACH LSAMP-BD FELLOW IN THEIR PROGRESSION AND ENTRANCE INTO THE PhD
PROGRAM. WE ARE ALSO REQUIRED TO TRACK YOUR PROGRESS THROUGH COMPLETION OF THE PhD PROGRAM.
STUDENT DATA ARE COLLECTED BY THE CSU-LSAMP STATEWIDE OFFICE AT CALIFORNIA STATE UNIVERISTY,
SACRAMENTO PRIOR TO SUBMISSION TO NSF. I ALSO UNDERSTAND THAT ONE OF THE CONDITIONS OF RECEIVING
THIS AWARD IS THAT I MUST MAINTAIN CONTACT WITH THE LSAMP COORDINATOR AT CAL STATE LA AFTER
COMPLETION OF MY TWO-YEAR MASTER’S GRADUATE DEGREE PROGRAM ON A YEARLY BASIS SO AS TO BE ABLE TO
KEEP NSF AND THE STATEWIDE CSU-LSAMP APPRISED OF MY ACCOMPLISHMENTS UNTIL AT LEAST MY PhD IS
AWARDED. I AUTHORIZE RELEASE AND USE OF THIS INFORMATION, AS DESCRIBED ABOVE, TO THE CSU-LSAMP
PROGRAM. I HAVE READ AND UNDERSTAND ALL OF THE STATEMENTS ABOVE.
SIGNATURE OF APPLICANT
PLEASE RETURN COMPLETED APPLICATION TO:
DR. MARGARET JEFFERSON
LSAMP-BD PROGRAM c/o DEPARTMENT OF BIOLOGICAL SCIENCES
CSU, LOS ANGELES
5151 STATE UNIVERSITY DRIVE
LOS ANGELES, CALIFORNIA 90032-8201
DATE
FOR MORE INFORMATION:
CONTACT: DR. MARGARET JEFFERSON
PHONE: 323/ 343-2059
E-MAIL: MJEFFER@CALSTATELA.EDU
DEADLINE TO APPLY FOR LSAMP-BD PROGRAM: MAY 13, 2016 (INCOMPLETE APPLICATIONS WILL NOT BE REVIEWED)
NOTE: MAKE SURE YOU HAVE APPLIED TO CAL STATE LA GRADUATE PROGRAM AND DEPARTMENT BEFORE YOU APPLY AND
SUBMIT THIS LSAMP-BD APPLICATION FORM. DEADLINE IS DEPARTMENT SPECIFIC & MAY BE AS EARLY AS MARCH 15, 2016.
The funding for this program is pending approval by the National Science Foundation. 6